MEDICARE: HEATHER L DERMYER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301014186	MI
2	103TC0700X	Clinical Psychologist	6301014186	MI

General Provider Information

NPI Number	:	1114230786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER L DERMYER PH.D.

Provider Business Mailing Address
First Line	:	12935 S WEST BAY SHORE DR STE 220
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-5470
Country	:	US
Telephone Number	:	231-590-7184
Fax Number	:	231-252-4042

Provider Business Practice Location Address
First Line	:	12935 S WEST BAY SHORE DR STE 220
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-5470
Country	:	US
Telephone Number	:	231-590-7184
Fax Number	:	231-252-4042

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2010
Last Update Date	:	07/02/2024

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